The Oncoming Train

The locomotive of change in healthcare is barreling down the tracks
toward us. We all feel helpless, unable to get off the tracks before
it runs us over. Change has been unkind over the past few decades -
alienating doctors and patients from each other and turning a
relationship that relies on trust into one full of suspicion.

Doctors want to be able to practice medicine without the hassle, and
patients want good care from doctors. Why can't change get us back to
this? With healthcare being the mess it is today, why is change still
so scary to nearly everyone?

The question of Quality

The problem that most consumers of healthcare face is that they
don't know who to trust. What constitutes high-quality healthcare?
This question is also reverberating through the medical community as
more "Pay for Performance" programs are adopted - linking physician pay
with quality measures. What quality measures? Who makes them?

Clearly healthcare is broken; both patients and physicians are
dissatisfied with the way that our system pays for healthcare. Our
system is perfectly designed to make doctors do the following:

Do more procedures (needed or not).

Spend less time with patients - Paid on a "per visit" basis, doctors make more by seeing more.

Disregard coordination of care - Time spent communicating with colleagues decreases pay for both physicians.

Not worry about the cost of care - Threat of lawsuits and patient
expectations often drive physicians to order more tests than necessary
and use medications seen on TV. It costs docs nothing to over-spend.

The care we desire is not at all like the care we pay for. This
makes changes in the payment system not only financially important, but
tied directly to the quality of care. "You get what you pay for," and
we are paying for quantity and ignoring quality.

But to pay more for quality, it is essential to be able to first
define quality. There are many stories of misguided guidelines that
were supposed to increase quality, but ended up hurting patients (a good example was given by ER physician White Coat). So how can quality be encouraged without causing these problems?

Angry Patients

Patients bear the brunt of the problems in healthcare, because
healthcare is about them. Bad doctors are better off than their
patients. Hurried doctors are frustrated, but their patients may be
harmed. A full waiting room is a good thing for a doctor but a bad
thing for a patient. This has caused a great deal of anger - much of
it directed towards doctors.

Another problem patients face is that they don't know what good care
looks like. How do you choose a doctor? How do you know you are
getting the best care for your problems? A lot of people have the same
mistrust of healthcare providers that they do with auto mechanics (but
with mechanics, at least you know how much they are charging you).
Medicine, on the other hand, has always been a black box for patients -
both in quality and cost. Care is given and billed for, and patients
have no idea if they have gotten their money's worth.

Recently there have been huge changes in the behavior of patients;
they double-check doctors on the Internet and openly question care
given ("doctor, won't that drug destroy my liver?"). This mistrust has
caused alternative medicine to flourish and has spawned multiple
doctor-rating sites on the Web. Physicians can complain about all of
this, but the reality is that patients are very dissatisfied with the
care they are getting and are starting to do something about it.

Foxes guarding Chickens

Seeing the dissatisfaction of patients, the insurance industry has
begun to rate physicians. They use the data they get from money they
pay out to various parties to make judgments on the quality of care
given. How many mammograms is a physician ordering? What percent of
drugs prescribed are generic? What are immunization rates, percent of
diabetics getting the proper care, and number of elderly people getting
flu shots? All of these can be inferred from the claims data.

They have used this data to send "report cards" on quality and to
rate physicians on their websites. They have also been the first to go
after "pay for performance" - programs that depend on the measurement
of quality to determine who deserves the bonus and who doesn't. But
there are huge problems with the insurance companies' serving as the
ones who measure and reward quality:

Their data is inaccurate. I checked the accuracy of an insurance
company report card against the clinical data on my EMR. 50% of the
deficiencies they reported were wrong. I subsequently sent them back a
report card on their report card, chiding them for the poor quality of
their work. They never answered.

Their self-interest is obvious. The main goal of a publicly-held
insurance company is to maximize their profits. To let them determine
which physicians will get extra payment is like having a fox guard the
chicken coop. They are far better served to judge quality as low and
not give bonuses than they are to send lots of bonus checks. I tried
to find out the data behind one P4P bonus I got (which I thought was
suspiciously low) and the insurer was "unable" to supply me with the
information.

No Alternative

While physicians rail against the dangers measuring quality and
rating physicians, most don't give an alternative. The current system
is untenable and unfair to those who try to practice quality medicine.
We have no alternative but to change it, and encouraging the value of
care (high quality at lower cost) needs to be the goal of any system.

Given this, I accept the fact that I will be graded. My
quality has to be measured for the system to at all change. I am
frustrated with being penalized for doing what's right, and so see the
need for my care to be measured in some way. It will happen; it's only
a question of who will grade and on what basis.

What is Needed

Here are the questions that must be addressed to have any hope for real success:

Whose Data? Claims data is inaccurate and owned by those with too
great a self-interest. The data used needs to be taken directly from
clinical care, and not from how it is billed. But self-reporting by
doctors is equally flawed, as they will do so in a way that maximizes
their own benefit.

What Data? What are good measurements of quality? There are some
clear guidelines that most physicians agree on, but the issue of
patient compliance always comes up. Is ordering a mammogram the
measure, or is it if the patient actually gets one done? What about
quality of service (which patients want to see)?

Who makes the call? Insurance companies, doctors, and patients all
have their self-interest, so none should run the show and none should
be excluded. Doctors have to be confident that correct data is used,
while insurers need to have some control over what they pay out.
Patients will be inherently (and justifiably) suspicious of any system
that excludes them.

How is it reported? Measurement is worthless if the data are ignored. All parties need to see the numbers. Some doctors would
rather the data be kept hidden. By definition, half of all physicians
are below average.

Given these factors, this is what I see as necessary components of any rating or pay-for-performance system:

Data should be gathered and analyzed in a way that minimizes the self-interest of the various parties involved.

Quality needs to be defined and agreed-upon. The comparative
studies by the government should help, but physician involvement (as I
said in my last post) needs to be high in the process of determining
the definition of quality.

Measurement should take patient compliance into account, rewarding
physicians for ordering tests or prescribing medications. Ideally,
patients would somehow be motivated by the system to be more compliant
(as is the case in some P4P programs).

Quality of service is important as well.

Reports of quality need to be accessible to all parties.

The devil, of course, is always in the details. But change seems
inevitable, and the only way that this change will have a chance of
improving things is if these things are taken into account. Do we
really want to wait for a government mandate? Do we really want to
depend on politicians to tell us how to practice medicine? Either we
become part of the solution, or we live with what is handed to us.

The basic transaction of healthcare is simple: doctor cares for
patient and patient pays doctor for that care. Both doctors and
patients have huge motivation to make sure this transaction happens as
fairly as possible. We need to be the engine behind change in
healthcare, not the woman tied to the tracks.

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